M.V AP MOELLER Mooring Accident Report by DMA

7/30/2019 M.V AP MOELLER Mooring Accident Report by DMA

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MARINE ACCIDENT REPORT

DIVISION FOR INVESTIGATION OF MARITIME ACCIDENTS

A P M O E L L E RA c c i d e n t t o s e a f a r e r

1 9 D e c e m b e r 2 0 0 9


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The casualty report has been issued on 08.06.2010

Case: 201000032

The casualty report is available on our homepage: www.dma.dk.

The Division for Investigation of Maritime Accidents

The Division for Investigation of Maritime Accidents is responsible for investigating ac-cidents and serious occupational accidents on Danish merchant and fishing vessels.The Division also investigates accidents at sea on foreign ships in Danish waters.

PurposeThe purpose of the investigation is to clarify the actual sequence of events leading tothe accident. With this information in hand, others can take measures to prevent similaraccidents in the future.

The aim of the investigations is not to establish legal or economic liability.

The Divisions work is separated from other functions and activities of the Danish Mari-

time Authority.

Reporting obligationWhen a Danish merchant or fishing vessel has been involved in a serious accident atsea, the Division for Investigation of Maritime Accidents must be informed immediately.

Phone: +45 39 17 44 00Fax: +45 39 17 44 16

E-mail: [email protected]

Cell-phone: +45 2334 2301(24 hours a day).

Division for Investigation of Maritime Accidents. Danish Maritime Authority,

Vermundsgade 38 C, DK 2100 Copenhagen

Phone: +45 39 17 44 00, Fax: +45 39 17 44 16, CVR-no.: 29 83 16 10

E-Mail: [email protected] www.sofartsstyrelsen.dk


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Contents

1 Summary .............................................................................................................. 42 Conclusion ............................................................................................................ 43 Initiatives and recommendations ........................................................................... 44

The investigation ................................................................................................... 5

5 Factual Information ............................................................................................... 6

5.1 Accident data ................................................................................................ 65.2 Navigation data ............................................................................................. 65.3 Ship data ....................................................................................................... 65.4 Weather data ................................................................................................. 65.5 The crew ....................................................................................................... 65.6 Narratives ...................................................................................................... 75.7 Mooring Equipment .................................................................................... 85.8 Mooring details and planning ...................................................................... 95.9 Mooring formalized written instruction....................................................... 105.10 Mooring Safe Job Analysis (SJA) ............................................................. 105.11 Safety work on board in general ............................................................... 105.12 Safety work on board after the accident .................................................... 115.13 Rest hours prior to the accident ................................................................... 11

6 Analysis .............................................................................................................. 126.1 Immediate causes ....................................................................................... 126.2 Contributory causes..................................................................................... 12

7 Enclosures .......................................................................................................... 147.1 Instruction for mooring operations (ID: 9829) ............................................... 147.2 SJA for mooring operations ......................................................................... 18


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1 Summary

The accident occurred on the forecastle deck during the mooring operation at depar-ture from Singapore.When heaving the spring lines, the messenger lines got entan-gled. This resulted in the spring lines tightening.Subsequently a rope guide broke anda spring line hit an AB on his right hip. The AB was slung against the windlass and sus-

tained injuries to his hip, head and arm.

2 Conclusion

The mooring winches were operated at high speed, which caused the messenger linesto entangle as the ends of the spring lines approached the roller fairleads. As a conse-quence the spring lines tightened. (6.1)

The rope guides did not have enough strength to absorb the load from the suddentightening of the spring lines. (6.1)

It is the assessment of the Division for Investigation of Maritime Accidents that the 2 ndofficer and the ABs either did not realize the risk associated with the job they were do-ing or tolerated the risk, given their previous experience in similar situations. (6.2)

It is the assessment of the Division for Investigation of Maritime Accidents that consis-tent safety planning and communication in connection with the mooring operation waslacking (6.2)

It is the assessment of the Division for Investigation of Maritime Accidents that thesafety assessment of the rope guide concept was inadequate. (6.2)

3 Initiatives and recommendations

InitiativesThe ship management has analysed the accident and issued an internal investigationreport.

Maersk Line has issued safety flash 01-/2010 on 12th March 2010 to all vessels regard-ing utilisation of Safe Job Analysis.

Maersk Line has issued safety flash 02-/2010 on 23rd April 2010 to all vessels regard-ing mooring operation.

Maersk Line has commenced a fleet campaign on safer mooring.

The main themes of the safer mooring campaign are:- Better planning means safer mooring- Complacency causes accidents- Always know where your team members are- Good communication with the bridge is essential

RecommendationsIn the period 1997-2005, OKE has processed 17 serious or very serious marine casual-ties related to mooring operations on merchant vessels, which have been compiled in asafety survey issued on 1 December 2006. The publication is in Danish and can be

found on:

http://www.soefartsstyrelsen.dk/ulykkesopklaring/publikationer/Sider/Temaundersgelser.aspx


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Consistent safety planning and communication in connection with mooring operationswas lacking on board. This may have contributed to a downgraded risk perception anda reduced safety awareness of the situation.

A safety assessment of the rope guide concept could have contributed positively to therisk perception and safety awareness in connection with mooring operations.

The Division for Investigation of Maritime Accidents recommends the shipping com-pany to:

- Ensure that safety planning and communication in connection with hazardousroutine tasks is maintained at a sustainable level on board.

- Ensure safety assessments of improvement concepts and suggestions as partof the implementation on board.

4 The investigation

The Division for Investigation of Maritime Accidents has made interviews and gatheredinformation on board AP MOELLER in Euro port.

The Division for Investigation of Maritime Accidents received Personal injury report, astatement of facts, pictures from the accident scene and an internal investigation reportfrom the vessel regarding the accident.

The Division for Investigation of Maritime Accidents has met with the Head of NauticalDepartment and the Process Safety Manager at Maersk Line head quarters in Copen-hagen.


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5 Factual Information

5.1 Accident dataType of accident (the incident in details) Accident to seafarerTime and date of the accident 1935 local time, 19 December 2009Position of the accident Alongside in Singapore

Area of accident Mooring deck, forecastleInjured persons Able bodied seamanIMO casualty class Serious

5.2 Navigation dataStage of navigation DeparturePort of departure Singapore

5.3 Ship dataName AP MOELLER

Home port DragrCall sign OVYQ2IMO no. 9214898ISM responsible operator/owner A.P. Moeller Maersk A/SRegister DISFlag State DenmarkConstruction year 2000Type of ship Container shipTonnage 91560 GTClassification ABSLength 346.98 mEngine power 54898 kWRegulation Notices from DMA B

5.4 Weather dataWind direction and speed NW 1-5 m/sSea CalmVisibility GoodIllumination Daylight

5.5 The crewNumber of crewmembers 25

Watch on the bridge 4-8 at sea. 6-6 at berthMinimum safe manning 13Occupation on board the ship at the time ofthe accident (crewmembers relevant to theaccident)

Age, certificate of competency, other cer-tificates, training, service at sea.

2nd officer Navigational officer, 37 years old. Em-ployed in A.P. Moeller Maersk since2006. STCW II/1. Nationality : Danish

Injured person (IP) Able bodied seaman. 50 years old. Em-ployed in A.P. Moeller Maersk since2003. 16 safety certificate. Nationality:Filipino


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2nd Officer

AB No. 2

In ured AB

5.6 NarrativesOn 19 December 2009 at 1620, the vessel was ready to depart Singapore berth andthe 2nd officer together with 2 AB's were on the forecastle to assist with the departure.

At 1622 the two first headlines were let go and taken on board and at 1627 the last twoheadlines were let go and taken on board.

At 1634 both port side spring lines were let go. Whilst the spring lines were beingheaved, one AB was controlling and assisting the aft spring line to spool properly onthe storage drum. The other AB was controlling and assisting the forward spring line tospool properly on the storage drum. See picture 1.

As the spring lines were approaching the adjacent roller fairleads, the messenger lines

entangled.

According to the 2nd officer, he looked over the side and after a moment of inattentionhe suddenly realized that the spring lines were very close to the roller fairleads. Heimmediately stopped the winches by setting the control handles in the stop position.However, the winches did not stop immediately resulting in heavy tightness of the lines.

The aft rope guide bended and the aft spring line flipped over the rope guide andsnapped back. The AB assisting was positioned aft of this spring line. He was hit by theline and was slung into the windlass foundation.

The forward rope guide broke off and the forward spring line snapped back. The AB

assisting was positioned forward of the line. He was not hit.

The 2nd officer immediately stepped down from the platform at the control panel to pro-vide aid to the injured AB.

Picture 1: Accident scene before the accident. (Arrangement by courtesy of Maersk Line)


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The master was also immediately advised and he decided to bring the vessel alongsideat once.

At 1636, the master called an emergency response team and an ambulance.

Shortly after the accident, the chief officer arrived at the forecastle with an AMBU unit

and stretcher and started recovery of the injured person.

At 1646, a shore-based Emergency Response Team and an ambulance arrived andtwo minutes later the vessel was alongside.

At 1649, the Emergency Response Team came on board to recover the injured person.

At 1719, the injured person was evacuated and transported to a hospital.

The AB sustained injuries to his hip, head and arm.

5.7 Mooring EquipmentWinchesThe vessel is equipped with six mooring winches on the forecastle deck according tothe arrangement in picture 1. The mooring winches are of the type Aquamaster-Raumawith split drums, i.e. a tension drum and a storage drum on the same shaft.

The winches are electrically powered and controlled from a central control panel on anelevated platform by the bulwark. The speed of the winches can be set in three steps.

The two combined windlass and mooring winches provide the following speed options:Low speed 12m/min. Medium speed 22m/min. High speed 44m/min.

The four dedicated mooring winches provide the following speed options: Low speed 9m/min. Medium speed 18m/min. High speed 54m/min.

According to Maersk Line Nautical Department, electric winches with stepwise speedadjustment are installed on the majority of the companys vessels. Some vessels havewinches with continuously variable speed. When electric winches with stepwise speedadjustment were introduced, the Nautical Department received complaints about thereduced flexibility compared to the flexibility provided by winches with continuouslyvariable speed.

According to the Nautical Department, personal safety aspects are not consideredwhen winches are specified or purchased during a new building project. Winches arenormally an off-the-shelf item provided by the building yard.

According to the Nautical Department optimized safety and functionality is alwaysaimed for when reviewing the preliminary arrangements as presented by differentyards, with due regard to design limitations.

Rope guidesThe purpose of the rope guides is to make it easier to spool the mooring lines in evenlayers on the storage drum with a minimum of manual handling.

Rope guides were introduced in the fleet a few years ago as an initiative to improve

safety in connection with mooring operations.


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Rope guides have not been systematically installed on all vessels but the concept hasbeen emphasized and promoted as a good idea to the vessels by Maersk Line NauticalDepartment.

The design, installation and implementation of the rope guide concept on a particularvessel are only managed on board. The structural design is approved by the chief en-gineer on board the particular vessel.

According to Maersk Line Nautical Department, several improvement con-cepts/suggestions from the vessel fleet, like the rope guides, have been recorded overtime and some have been shared with the entire fleet. It is the intention to publish acatalogue of good ideas when all vessels come online during this year.

Observations had been made previously on board of messenger lines getting entan-gled and rope guides being bended.

5.8 Mooring details and planningAccording to the master and 2nd officer, the 2nd officer was designated responsible per-son on the mooring deck.

According to the 2nd officer, the mooring operation was a routine task and thus not sub-ject to any planning apart from the mooring plan, which was pointed out by the master.

As the lines were let go, the winch speed was set in position 3 at the highest speedpossible in order to get the mooring lines clear of the water and hence the thrusters. Asthe lines came clear of the water the operation of the winches continued at the highest

speed.

Picture 2: Spring line and rope guide. (Picture by courtesy of Maersk Line)


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According to the Nautical Department, heaving at high speed after the mooring linesare clear of the water is not unseen on board the companys vessels. Despite this, it isnot recognized as best practice.

According to the 2nd officer, it was his plan to reduce the speed as the spring linescame clear of the water. He did not know why he did not reduce the speed, which heconsiders the right thing to do.

The 2nd officer noted that masters on some vessels did not have sufficient patience towait for the lines to be heaved at medium speed, but this was not the case with theactual master on board.

According to the 2nd officer, the injured AB was positioned forward of the spring linewhen the spring lines were let go. He did not notice that the injured AB changed posi-tion from forward of the spring line to aft of it.

Both the 2nd officer and the injured AB have long experience with mooring operations.

5.9 Mooring formalized written instructionThe instruction for mooring operations (ID: 9829) is contained in the on-board GlobalShip Management System (GSMS). See enclosure 7.1.

The purpose of the instruction is To specify a global approach to mooring operationsand use of mooring equipment.

It describes in general terms:- The personnel and their responsibilities.- Personal protective equipment to be worn.- How mooring areas should be maintained.- The mooring procedure.

- How to handle the various types of mooring equipment.

5.10 Mooring Safe Job Analysis (SJA)Hazardous work on board is risk managed by a process described in a risk manage-ment procedure which is contained in the on-board Global Ship Management System(GSMS).

An SJA is one out of six main elements in the process of risk management. All six ele-ments are not always to be considered while assessing a task.

An SJA is ship specific and made on board.

There is a separate SJA for mooring operations. See enclosure 7.2.

The SJA for mooring operations describes by which control measures a given riskcould be reduced.

The 2nd officer was aware that an SJA for mooring was available in the deck office.

It was not his understanding that SJAs should be used as reference in daily routinetasks.

5.11 Safety work on board in generalAll crew members are to go through a familiarization process within 72 hours after hav-ing signed on. A certain number of familiarization items have to be completed within 24


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hours. The majority of the items are related to safety on board. All persons involved inthe accident had signed an attendance sheet.

Safety meetings are held on board on a monthly basis.

According to the minutes from the safety meetings, several safety related issues, suchas safety flashes, technical flashes, incident reports, near misses, on board area in-

spections, etc., have been discussed.

According to the master, mooring situations are discussed on a regular basis at thesafety meetings but the actual type of mooring accident had not been discussed.

According to the minutes from the recent six safety meetings before the accident,mooring operations had not been on the agenda.

A Video On Demand System (VOD) is available on board and has been introduced atsafety meetings before the accident. The videos cover various safety topics, includingmooring operations.

There is evidence that the daily work lists have been used to communicate safety in-structions and to address safety awareness.

5.12 Safety work on board after the accidentAfter the accident, the following steps were taken:

- The master and chief officer conducted an accident investigation, where riskand non-risk areas on the mooring deck were discussed.

- An extraordinary safety meeting was held, where the details from the accidentwere discussed.

- The master and chief officer reassessed the SJA for mooring and amended it toreflect the lessons learnt from the accident.

As a part of the daily work list, the crew has been requested to watch relevant videoson demand such as the one on safe mooring practice.

After the monthly fire/boat/MOB/SOPEP drills, the participants are being asked aboutrelated safety matters.

5.13 Rest hours prior to the accident

According to the rest hour sheets, the 2

nd

officer had rested between 14-16 hours perday during the week leading up to the accident.

On the day of the accident, the 2nd officer began his watch at 1200 after six hours con-secutive rest. According to the 2nd officer, he felt fit and rested.

According to the rest hour sheets, the AB had rested between 12-14 hours per dayduring the week leading up to the accident.

On the day of the accident, the AB began his watch at 0800 after 13 hours consecutiverest.


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6 Analysis

6.1 Immediate causes

Unsafe actionsThe mooring winches were operated at the highest speed.

The injured AB and his colleague were guiding the spring lines on the storage drumswhile they were being heaved at high speed.

During the mooring operation, the injured AB changed position from forward of themooring line to aft. In this position, the AB stood in a latent snapback zone.

The 2nd officer was inattentive for a moment.

The mooring winches were operated at high speed, which caused the messenger linesto entangle as the ends of the spring lines approached the roller fairleads. As a conse-quence the spring lines tightened.

Unsafe surroundingsThe aft rope guide bended and the aft spring line flipped over the rope guide andsnapped back.

The forward rope guide broke off and the forward spring line snapped back.

The winches did not stop at once when the control handle was released due to inertiain the winch system.

The rope guides did not have enough strength to absorb the load from the suddentightening of the spring lines.

6.2 Contributory causes

Involved personsBoth the 2nd officer and the injured AB had long experience with mooring operations.

According to the Nautical Department, heaving at high speed after the mooring linesare clear of the water is not unseen on board the companys vessels. Despite this, it isnot recognized as best practice.

Observations had been made previously on board of messenger lines getting entan-

gled and rope guides being bended.

It was possible to adjust the winch speed in three steps with large increments.

The 2nd officer noted that masters on some vessels did not have sufficient patience towait for the lines to be heaved at medium speed, but this was not the case with theactual master on board.

It is the assessment of the Division for Investigation of Maritime Accidents that the 2 ndofficer and the ABs either did not realize the risk associated with the job they were do-ing or tolerated the risk, given their previous experience in similar situations.


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The Safety system

Mooring operationsAccording to the 2nd officer, the mooring operation was a routine task and thus not sub-ject to any planning apart from the mooring plan, which was pointed out by the master.

According to the minutes from the recent six safety meetings before the accident,

mooring operations had not been on the agenda

The 2nd officer was aware that an SJA for mooring was available in the deck office.

It was not his understanding that SJAs should be used as reference in daily routinetasks.

The SJA for mooring operations describes by which control measures a given riskcould be reduced.

The SJA for mooring operations does not describe how the control measures should beachieved. I.e. the SJA says that the risk can be reduced by Adequate supervision andtraining but does not define or discuss what adequate supervision and training means.

It is the assessment of the Division for Investigation of Maritime Accidents that consis-tent safety planning and communication in connection with the mooring operation waslacking.

Rope guide designThe design, installation and implementation of the rope guide concept on a particularvessel are only managed on board. The structural design is approved by the chief en-gineer on board the particular vessel.

It had been observed previously that rope guides had been bended by mooring lines.

It is the assessment of the Division for Investigation of Maritime Accidents that thesafety assessment of the rope guide concept was inadequate.


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7 Enclosures

7.1 Instruction for mooring operations (ID: 9829)


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7.2 SJA for mooring operations


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M.V AP MOELLER Mooring Accident Report by DMA

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